BY MARK SCHOLZ, MD
Osteoporosis is defined as calcium loss from the bones. It is a silent process until suddenly a fracture occurs. Common sites of fracture are the spine, rib, wrist, and hip. Fractures of the spine, called compression fractures, can result in loss of height with forward curvature of the back. Osteoporosis is incorrectly believed to only appear in females. Actually, one-third of all hip fractures occur in men.
CAUSES OF OSTEOPOROSIS
Studies show a relationship between a lack of testosterone and the onset of osteoporosis. Other causes of osteoporosis include hyperactive thyroid or parathyroid glands, excessive alcohol use, cortisone use, lack of exercise and low vitamin D.
The earlier osteoporosis is diagnosed the more treatable it is. Unfortunately, the most common scanning technique for diagnosing osteoporosis—the Dual-energy X-ray absorptiometry (DEXA) scan—is not terribly accurate in men because it underestimates the degree of osteoporosis in the spine. A more accurate technique is Quantitative Computed Tomography (QCT). However, QCT is not widely available and finding an imaging center that does QCT may be difficult.
Certain simple behaviors can forestall the development of osteoporosis. One should begin with exercise, vitamin D supplements, and a low dose of calcium at bedtime. A typical protocol is 250 mg of calcium at bedtime along with 2,000 units of vitamin D. Blood levels of vitamin D should be checked after 3 months and the dosage should be adjusted accordingly. Various pharmaceuticals (see below) can be very effective at counteracting osteoporosis.
BISPHOSPHONATES: BONIVA, ACTONEL, FOSAMAX AND ZOMETA
Bisphosphonates come in both oral and intravenous (infusion) forms. When taken orally, adequate absorption into the blood only occurs when administered on an empty stomach. The most common side effects from an oral bisphosphonate are stomach or esophageal irritation. Intravenous Zometa bypasses the stomach and avoids stomach irritation. Zometa is more potent because 100% of the drug gets into the system while with oral preparations only 1-2% of the drug is absorbed. The most common side effect from Zometa is a brief, flu-like muscle soreness lasting a day or so. Zometa is typically given every three to six months.
DENOSUMAB INJECTIONS: PROLIA AND XGEVA
Denosumab injections are available in two strengths. A half-dose shot called Prolia is administered every 6 months for osteoporosis. A full-dose shot called Xgeva is given monthly for the prevention of cancer growth in the bone.
OSTEONECROSIS, A SERIOUS JAW PROBLEM
Zometa and denosumab and, to a much lesser degree, oral bisphosphonates can induce jaw damage, a condition termed osteonecrosis. This is uncommon but the risks increase with prolonged use of pharmaceuticals or after a tooth extraction. To minimize the risk of osteonecrosis some experts are using Xgeva quarterly instead of monthly. When osteonecrosis occurs, the gum tissue recedes, leaving exposed bone, which is susceptible to recurrent infections. In my experience, osteonecrosis slowly reverses after the medication is stopped.
Eventually, some degree of osteoporosis occurs in most men as they age. Bone density screening should begin in men around 60 so the condition can be detected and treated early, when it is most responsive to therapy. Men receiving hormonal therapy, treatment that blocks testosterone, for prostate cancer should use a preventative approach and begin treatment early before osteoporosis develops.